By Counterforce Health Team in Xywav (Ca/Mg/K/Na oxybates) —

How to Get Xywav (Ca/Mg/K/Na oxybates) Covered by Cigna in Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Xywav Covered by Cigna in Michigan

Cigna requires prior authorization for Xywav (Ca/Mg/K/Na oxybates) with mandatory REMS enrollment. The fastest path: (1) Complete REMS certification for both prescriber and patient, (2) Submit PA via CoverMyMeds with sleep study reports and step therapy documentation, (3) If denied, file internal appeal within 180 days, then external review with Michigan DIFS within 127 days. Start today by calling Cigna at 1-800-882-4462 to verify current PA requirements and confirm your specialty pharmacy network.

Table of Contents

  1. Prior Authorization Requirements
  2. REMS Program Enrollment
  3. ICD-10 Coding and Documentation
  4. NDC and Billing Basics
  5. Step-by-Step: Fastest Path to Approval
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Michigan
  8. Costs and Patient Assistance
  9. FAQ

Prior Authorization Requirements

Cigna requires prior authorization for Xywav as of January 2026, with review timelines of 5 business days for complete submissions. The medication is typically managed through Express Scripts/Accredo as a specialty drug under the pharmacy benefit using NDC 68727-0150-01 (180 mL bottle, 0.5 g/mL concentration).

Coverage at a Glance

Requirement Details Source
Prior Auth Required Yes, effective January 1, 2026 Cigna Policy Updates
REMS Enrollment Mandatory for prescriber and patient Cigna Oxybate Policy
Step Therapy First-line stimulants or modafinil required Cigna PA Criteria
Diagnosis Codes G47.411 (narcolepsy with cataplexy), G47.11/G47.12 (IH) ICD-10 Reference
Billing Method Pharmacy benefit via NDC, not J-code NDC Database

REMS Program Enrollment

Both prescriber and patient must complete REMS enrollment before Cigna will approve coverage. This is the most common reason for initial denials.

Required Steps:

  1. Prescriber: Complete Xyrem REMS certification at xywavxyremrems.com
  2. Patient: Enroll in Xyrem Success Program
  3. Pharmacy: Must use certified specialty pharmacy (typically Accredo for Cigna members)
Tip: Complete REMS enrollment before submitting your PA to avoid automatic denial. Keep confirmation numbers for your records.

ICD-10 Coding and Documentation

Primary Diagnosis Codes

Condition ICD-10 Code Documentation Required
Narcolepsy with cataplexy G47.411 PSG + MSLT + cataplexy episodes
Narcolepsy without cataplexy G47.419 PSG + MSLT (≥2 sleep-onset REM periods)
Idiopathic hypersomnia with long sleep G47.11 PSG + MSLT + sleep duration >10 hours
Idiopathic hypersomnia without long sleep G47.12 PSG + MSLT + normal sleep duration

Clinical Documentation Requirements

Your sleep specialist must provide:

  • Polysomnography (PSG) results excluding other sleep disorders
  • Multiple Sleep Latency Test (MSLT) with mean sleep latency ≤8 minutes
  • Cataplexy documentation (for narcolepsy): frequency, triggers, and severity
  • Epworth Sleepiness Scale scores showing excessive daytime sleepiness
  • Functional impairment assessment affecting work, school, or daily activities

NDC and Billing Basics

Product Information

  • NDC: 68727-0150-01 (primary billing code)
  • Concentration: 0.5 g/mL (180 mL bottle)
  • Benefit: Pharmacy (not medical)
  • No J-code: Use NDC only; if medical benefit required, use J3590 (unclassified oral drug)

Dosing and Quantity Calculations

Nightly Dose mL per Night Monthly mL (30 days) Bottles Needed
4.5 g 9 mL 270 mL 2 bottles
6.0 g 12 mL 360 mL 2 bottles
7.5 g 15 mL 450 mL 3 bottles
9.0 g 18 mL 540 mL 3 bottles
Note: Xywav bottles contain 180 mL each (vs. 240 mL for Xyrem). Calculate monthly supply carefully to avoid quantity limit denials.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Network (Day 1)

  • Call Cigna at 1-800-882-4462 to confirm current PA requirements
  • Verify Accredo is your assigned specialty pharmacy
  • Obtain member ID and group number for PA submission

2. Complete REMS Enrollment (Days 1-3)

  • Prescriber completes certification at xywavxyremrems.com
  • Patient enrolls in Xyrem Success Program
  • Obtain confirmation numbers for PA submission

3. Gather Required Documentation (Days 2-5)

  • Sleep study reports (PSG and MSLT)
  • Specialist consultation notes with diagnosis confirmation
  • Prior medication trials with specific dates, dosages, and outcomes
  • Current symptom assessments (Epworth Sleepiness Scale)

4. Submit Prior Authorization (Day 5)

Recommended method: CoverMyMeds

  • Create account and verify prescriber NPI
  • Select Xywav and complete PA form
  • Upload all supporting documentation
  • Track status via dashboard

Alternative: Fax to 1-855-840-1678 with confirmation receipt

5. Follow Up (Days 6-10)

  • Check submission status after 3 business days
  • Respond promptly to any requests for additional information
  • Expect decision within 5 business days of complete submission

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
No REMS enrollment Complete enrollment before resubmission REMS confirmation numbers
Step therapy not met Document stimulant trials or contraindications Trial dates, dosages, outcomes, or medical contraindications
Missing sleep studies Submit comprehensive sleep evaluation PSG and MSLT reports meeting diagnostic criteria
"Not medically necessary" File appeal with clinical guidelines Functional impairment documentation, treatment goals
Quantity limits exceeded Justify dosing based on clinical response Weight-based dosing rationale, titration schedule

Clinician Corner: Medical Necessity Letter Checklist

When appealing a "not medically necessary" denial, include:

  • Problem statement: Specific diagnosis with ICD-10 code
  • Prior treatments: Failed stimulants with dates, dosages, and reasons for discontinuation
  • Clinical rationale: Why Xywav is uniquely appropriate for this patient
  • Guideline support: Reference FDA labeling for approved indications
  • Treatment goals: Measurable outcomes expected with therapy
  • Monitoring plan: How response will be assessed and documented

Appeals Process in Michigan

If your PA is denied, Michigan residents have robust appeal rights under the Patient's Right to Independent Review Act.

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 15 days for expedited
  • How to file: Call Cigna member services or submit via member portal
  • Required: Written appeal with medical necessity documentation
  • Tip: Request peer-to-peer review between prescriber and Cigna medical director

External Review (Second Level)

  • Deadline: 127 days from final internal denial
  • Authority: Michigan Department of Insurance and Financial Services (DIFS)
  • Timeline: 60 days standard, 72 hours expedited
  • How to file: DIFS External Review Request form online or via fax
  • Cost: Free to patients
  • Decision: Binding on Cigna if overturned
Michigan Advantage: DIFS has a strong consumer protection track record. Success rates exceed 80% with proper documentation, particularly for rare disease treatments with FDA approval.

Contact DIFS: 877-999-6442 (toll-free) for appeal assistance and forms.

Costs and Patient Assistance

Manufacturer Support

  • JazzCares Patient Assistance Program: Income-based free drug program
  • Copay assistance: Up to $6,000 annually for commercially insured patients
  • Information: Visit jazzcares.com or call 1-800-394-2792

Additional Resources

  • Accredo Specialty Pharmacy: Often provides prior authorization support for Cigna members
  • Patient Advocate Foundation: Free case management for insurance appeals
  • Michigan 211: Dial 2-1-1 for local assistance programs and resources

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed rebuttals aligned to each plan's specific policies. Our platform ingests denial letters, plan policies, and clinical notes to identify the exact denial basis and draft targeted appeals that address payer requirements point-by-point.

FAQ

How long does Cigna prior authorization take for Xywav? Standard review is 5 business days for complete submissions. Expedited review (72 hours) is available for urgent cases by calling 1-800-882-4462.

What if Xywav is non-formulary on my Cigna plan? Request a formulary exception using Cigna's exception process. Include documentation of medical necessity and contraindications to formulary alternatives.

Can I appeal if I've tried step therapy medications outside Michigan? Yes. Document previous trials with medical records showing dates, dosages, and reasons for discontinuation. Cigna must accept valid prior therapy regardless of location.

Does Cigna cover once-nightly dosing for idiopathic hypersomnia? Yes, FDA-approved once-nightly dosing (up to 6g) for IH is covered when medically appropriate and properly documented.

What happens if my appeal is denied in Michigan? File for external review with Michigan DIFS within 127 days. The independent medical review is binding and free to patients.

Can my doctor request expedited review? Yes. Expedited PA review (72 hours) requires physician attestation that delay would harm the patient's health.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current coverage policies and requirements. Coverage decisions may vary based on individual circumstances and plan details.

For complex denials or appeals assistance, Counterforce Health provides specialized support in creating evidence-based appeals that address specific payer requirements and improve approval rates.

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